住院2型糖尿病患者血压控制的影响因素

目的探讨住院2型糖尿病(type2diabetes mellitus,T2DM)患者血压控制的影响因素。方法 169例合并原发性高血压(高血压)的T2DM患者给予降压等综合治疗,以出院时血压130/80mm Hg(1mm Hg=0.133kPa)为界限分为达标组(n=97)及未达标组(n=72),比较两组入院时临床及实验室指标,并通过回归分析观察各种因素对出院时平均动脉压水平的影响。结果全组T2DM入院时收缩压为(143±15)mm Hg,舒张压为(78±8)mm Hg,控制达标率仅17.8%;出院时血压达标率57.4%,降压药物种类平均增加1种。未达标组患者入院时收缩压[(151±15)mm Hg vs.(137±12)mm Hg,P0.05)、舒张压[(80±9)mm Hg vs.(77±7)mm Hg,P0.05]均高于达标组,且血清总胆固醇浓度及24h尿白蛋白排泄率显著升高。回归分析显示,平均动脉压与入院时收缩压、舒张压、血清总胆固醇及高血压病程显著正相关,与年龄负相关;平均动脉压与尿白蛋白排泄率显著正相关(r=0.303,P0.01)。合并糖尿病肾病患者随尿白蛋白排泄率增多而收缩压显著升高,大量蛋白尿者需要多种降压药物联合治疗且血压难以控制。结论 T2DM患者门诊血压控制达标率低;住院T2DM患者血压控制受入院时血压水平、高血压病程、高胆固醇血症、高尿白蛋白排泄率等因素影响;尿白蛋白排泄率增加可能是合并糖尿病肾病患者血压难以控制的直接原因。     

Evaluation of blood pressure control by ambulatory blood pressure monitoring and study of factors associated with poor blood pressure control in 300 treated hypertensive type 2 diabetic patients

Hypertension is frequently associated with type 2 diabetes and is often difficult to control.

Aim

Evaluate the frequency of controlled hypertension in our type 2 diabetic patients with known and treated hypertension and determine the factors associated with poor blood pressure control.

Subjects and methods

Prospective study concerning 300 type 2 diabetic patients with a known and treated hypertension, sex-ratio: 0.64, mean age: 61.2 ± 9.1 years (37–86). All subjects underwent physical examination, biological investigations and a 24 hours ambulatory blood pressure monitoring (ABPM).

Results

Hypertension was well controlled in 70 patients (23.3%). The concordance rate between clinical measure of blood pressure and ABPM was 70.3%. Subjects with uncontrolled hypertension were older (61.8 ± 8.9 vs 59.1 ± 9.3 years, P < 0.05), more frequently of male sex (sex-ratio: 0.77 vs 0.34, P < 0.01), smokers (36.4 vs 21.7%, P < 0.05) and with abdominal adiposity (P < 0.05). Duration of diabetes, body mass index and the frequency of peripheral neuropathy, retinopathy and coronary insufficiency were not different between the two groups. Diabetic nephropathy was more frequent (29.8 vs 16.1%, P < 0.05) in the group with uncontrolled hypertension. Loss of circadian blood pressure rhythm was noted in 239 patients (79.6%) and it was more frequently observed in patients with uncontrolled hypertension (84 vs 66%, P < 0.001).

Conclusion

Our type 2 diabetic patients had a poorly controlled hypertension. Close monitoring of blood pressure with adjustment of antihypertensive treatment are necessary to improve cardiovascular prognosis of our patients.     

住院2型糖尿病患者短期血压控制及影响因素探讨

目的:探讨住院2型糖尿病(T2DM)患者短期血压控制效果及影响因素.方法:169例伴发高血压的T2DM患者给予降压等综合治疗,以出院时血压130/80 mmHg(1 mmHg=0.133 kPa)为界限分为达标组(97例)及未达标组(72例),比较2组入院时临床及实验室指标,并通过回归分析观察各种因素对出院时平均动脉压(MAP)水平的影响.结果:全组T2DM入院时收缩压(SBP)为(143±15)mmHg,舒张压(DBP)为(78±8)mmHg,控制达标率仅17.8%;出院时血压达标率57.4%,降压药物种类平均增加0.8种.未达标组患者入院时SBP[(151±15)∶(137±12)mmHg,P<0.01]、DBP[(80±9)∶(77±7)mmHg, P<0.01]均高于达标组,且TC及24 h尿白蛋白排泄率(UAE)显著升高.回归分析显示MAP与入院时SBP、DBP、TC及高血压病程显著正相关,与年龄呈负相关;MAP与UAE显著正相关(r=0.303, P<0.01).并发糖尿病肾病(DN)患者随UAE增多而SBP显著升高,大量蛋白尿者需要多种降压药物联合且血压难以控制.结论:T2DM患者门诊血压控制达标率低,住院短期治疗明显改善了血压控制水平;住院T2DM患者血压控制受入院时血压水平、高血压病程、高胆固醇血症、高UAE等因素影响;UAE增加可能是并发DN患者血压难以控制的直接原因.     

合并高血压的老年2型糖尿病患者血压控制目标探讨

目的探讨老年2型糖尿病合并高血压患者降压的目标值。方法选取2008年1月至2011年1月在福建省立医院内科就诊的707例65岁以上老年2型糖尿病合并高血压患者,其中男324例,女383例,平均年龄（72±6）岁。按收缩压（SBP）高低分为收缩压严格控制组（130mm Hg≤SBP〈140mmHg,1mmHg=0．133kPa）235例,收缩压宽松控制组（140mmHg≤SBP〈160mm Hg）472例,两组患者收缩压水平均维持至少3年。所有患者进行12导联心电图检查,预估肾小球滤过率（eGFR）通过Cockcroft—Gault公式计算。将心电图aVL导联R波的电压（RaVL）作为心血管风险的替代指标,将eGFR作为评价肾功能的指标。以RaVL≥0．57mV和〈0．57mV作为二分类变量,使用logistic回归法分析心血管疾病风险。结果收缩压宽松控制组与严格控制组RaVL分别为：0,55（0．50～0．59）、0．58（0．52～0．64）mV,差异无统计学意义（F：0．235,P〉0．05）。收缩压宽松控制组eGFR为55．6（53．2～58．0）ml／min,低于收缩压严格控制组[59．6（56．2～63．1）ml／min],但差异无统计学意义（F=1．289,P〉0．05）。将RaVL≥0．57mV及RaVL〈0．57mV作为因变量进行多因素logistic回归分析发现,收缩压宽松控制组RaVL≥0．57mV的风险与收缩压严格控制组相比差异无统计学意义（OR=0．927,95％CI：0．567～1．514,P〉0．05）。结论老年2型糖尿病合并高血压患者收缩压的目标值控制在140mm Hg以下可能并不改善心血管和肾脏预后。     

血糖控制不佳2型糖尿病患者轻度认知障碍影响因素研究

目的探讨血糖控制不佳2型糖尿病患者(T2DM)轻度认知障碍(MCI)发生的影响因素,为疾病预防与控制提供依据。方法入选2014年10月至2015年5月安徽医科大学第一附属医院和第二附属医院内分泌科T2DM患者181例,其中男性105例,女性76例,年龄45～75(59.0±8.5)岁,采用长沙版蒙特利尔认知评估量表(MoCA)评定患者的总体认知,了解认知损害现状并根据得分分组分析影响因素。应用SPSS 16.0统计软件对数据进行分析。采用t检验或x2检验比较组间差异。单因素分析影响T2DM患者认知功能的因素,进一步采用logistic回归分析发生MCI的危险因素。结果血糖控制不佳T2DM患者的MCI患病率为52.5%(95/181)。单因素分析显示年龄、性别、文化程度、家庭人均月收入、饮酒、吸烟、脑梗死史、糖尿病周围神经病变、低血糖史和尿微量白蛋白/肌酐比值(A/C)比值与MCI相关(P0.05)。多因素logistic回归显示年龄与MCI正相关(OR=1.437,95%CI 1.017～2.029;P0.05),教育程度和低血糖史与MCI负相关(OR=0.326,95%CI0.197～0.539;OR=0.400,95%CI0.167～0.958;P0.05)。结论医务人员应关注血糖控制不佳T2DM患者的认知功能,及时采取措施延缓认知功能减退。     

A nationwide assessment of blood pressure control and the associated factors in Chinese type 2 diabetes mellitus patients

A subgroup analysis of the nationwide, cross‐sectional 3B STUDY was performed to understand the current blood pressure (BP) control status and treatment patterns in Chinese diabetes patients as well as to identify factors associated with BP control. The demographic data, anthropometric parameters, and laboratory results were collected from 24 512 type 2 diabetes patients. The BP goal was a systolic BP <130 mm Hg and a diastolic BP <80 mm Hg regardless of a history of hypertension or current antihypertensive treatment. The overall prevalence of hypertension was 59.9% with geographical differences. Among the diabetes patients with hypertension, 76.9% received antihypertensive medicines. Calcium channel blockers (39.3%), angiotensin II receptor antagonists (26.6%), and then β‐blockers (14.0%) or angiotensin‐converting enzyme inhibitors (13.6%) were frequently used for BP control. Only 17.5% (n = 2658) of diabetes patients with hypertension reached the recommended target BP. Body mass index <24 kg/m², urban resident, frequent physical activity, good adherence to medication, comorbidity with cardiovascular disease, achieving glycemic goal (HbA1c <7.0%), achieving lipid goal (low‐density lipoprotein cholesterol <2.59 mmol/L) were independent factors that predicted achievement of target BP goal. On the contrary, comorbidity with chronic kidney disease predicted failure to achieve target BP goal. Patients who were treated in a cardiology department or lived in the North were more likely to achieve BP goals. A considerable proportion of diabetic patients failed to achieve guideline‐recommended BP targets. More aggressive efforts should be made to overcome the diverse barriers and facilitate the optimization of diabetes management.     

Intensive blood pressure control affects cerebral blood flow in type 2 diabetes mellitus patients

Type 2 diabetes mellitus is associated with microvascular complications, hypertension, and impaired dynamic cerebral autoregulation. Intensive blood pressure (BP) control in hypertensive type 2 diabetic patients reduces their risk of stroke but may affect cerebral perfusion. Systemic hemodynamic variables and transcranial Doppler-determined cerebral blood flow velocity (CBFV), cerebral CO2 responsiveness, and cognitive function were determined after 3 and 6 months of intensive BP control in 17 type 2 diabetic patients with microvascular complications (T2DM+), in 18 diabetic patients without (T2DM-) microvascular complications, and in 16 nondiabetic hypertensive patients. Cerebrovascular reserve capacity was lower in T2DM+ versus T2DM- and nondiabetic hypertensive patients (4.6±1.1 versus 6.0±1.6 [P<0.05] and 6.6±1.7 [P<0.01], Δ%mean CBFV/mm Hg). After 6 months, the attained BP was comparable among the 3 groups. However, in contrast to nondiabetic hypertensive patients, intensive BP control reduced CBFV in T2DM- (58±9 to 54±12 cm·s(-1)) and T2DM+ (57±13 to 52±11 cm·s(-1)) at 3 months, but CBFV returned to baseline at 6 months only in T2DM-, whereas the reduction in CBFV progressed in T2DM+ (to 48±8 cm·s(-1)). Cognitive function did not change during the 6 months. Static cerebrovascular autoregulation appears to be impaired in type 2 diabetes mellitus, with a transient reduction in CBFV in uncomplicated diabetic patients on tight BP control, but with a progressive reduction in CBFV in diabetic patients with microvascular complications, indicating that maintenance of cerebral perfusion during BP treatment depends on the progression of microvascular disease. We suggest that BP treatment should be individualized, aiming at a balance between BP reduction and maintenance of CBFV.     

Medication non-adherence and poor glycaemic control in patients with type 2 diabetes mellitus

AimsHyperglycemia causes generation of free radicals which leads to oxidative stress and apoptosis in various cells. The present study was undertaken to investigate the correlation between oxidative stress and apoptotic markers in lymphocytes of diabetic patients with chronic non healing wounds.MethodsThirty healthy, thirty uncontrolled type 2 diabetes mellitus (T2DM) and thirty uncontrolled T2DM with chronic, non healing, neuropathic diabetic foot patients were included in this study. Indices of oxidative stress inside the lymphocyte lysate were estimated by measuring content of superoxide dismutase (SOD), Catalase, Glutathione and malonaldialdehyde (MDA). Protein expression studies of pro and anti apoptotic markers were carried out to elucidate their possible involvement in diabetic context.ResultsSOD and MDA activity was significantly higher in the lymphocytes of diabetic patients having chronic, non healing diabetic wound as compared with healthy (p < 0.001); whereas catalase and GSH activity was significantly reduced (p < 0.001) in the same group. Expressions of pro apoptotic markers (Caspase-3, Fas and Bax) were significantly higher whereas reduced expression of anti-apoptotic marker (Bcl-2) were obtained in lymphocytes of diabetic and non diabetic individuals.ConclusionsHyperglycemia confers pro apoptotic manifestations which are mostly through altered indices of oxidative stress within lymphocytic milieu.     

老年2型糖尿病患者平衡能力的相关危险因素分析

目的 探讨65岁及以上病程＞10年的2型糖尿病（T2DM）患者平衡能力及其相关危险因素.方法 2011年5月至9月选取97例65岁及以上病程＞10年的T2DM患者以及59名65岁及以上非糖尿病健康人群进行Berg平衡量表、足部振动觉、压力觉、温度觉、踝肱比、人体成分分析等测试,测定血清25羟维生素D3 [25 （OH） D3]、1,25二羟维生素D3[1.25（OH）2D3]水平,询问近12个月内跌倒次数并采集相关生化及临床指标.应用Spearman相关分析以及多元线性回归方法筛选平衡能力相关因素.结果 糖尿病组未受外力作用且与低血糖无关的跌倒发生率[27.8％（18/97）比10.17％（6/59）,χ^2=6.230]、人年均跌倒次数[（0.41±0.08）比（0.12±0.05）次,t=2.570]均明显高于对照组,Berg量表评分[（48.0±1.8）比（50.4±1.4）分,t=-8.900]、振动觉[（17±5）比（13±3）V,f =4.970]、踝肱比（0.79 ±0.11比0.97 ±0.16,t=-8.430）、压力觉（正常比例68.0％比89.8％,χ^2=9.627）、温度觉（正常比例52.6％比69.5％,χ^2=4.338）均低于对照组,差异均有统计学意义（均P＜0.05）.Spearman相关分析提示糖尿病组患者Berg量表评分与振动觉呈负相关（r=-0.760,P＜0.05）,与压力觉、踝肱比呈正相关（r=0.556、0.472,均P＜0.05）,多元线性回归提示振动觉和压力觉为Berg量表评分的独立影响因素（β=-0.702、0.251,均P＜0.05）.结论 65岁及以上病程＞10年的T2DM患者平衡能力明显减退,振动觉、压力觉是影响其平衡能力的独立危险因素.     

Patient-reported barriers and outcomes associated with poor glycaemic and blood pressure control in co-morbid diabetes and chronic kidney disease

Aims

In patients with comorbid diabetes and chronic kidney disease, the extent to which patient-reported barriers to health-care and patient reported outcomes influence the quality of health care is not well established. This study explored the association between patient-reported barriers to health-care, patient activation, quality of life and diabetes self-care, with attainment of glycaemic and blood pressure (BP) targets.

罗格列酮对2型糖尿病患者血压的影响

目的 观察胰岛素增敏剂罗格列酮治疗2型糖尿病伴高血压患者，评价其降压作用，探讨其降压机理。方法 32例2型糖尿病患者按血压分组，口服罗格列酮(文迪雅)4～8mg／d，共8w，计算胰岛素敏感指数和抵抗指数。结果 罗格列酮分别降低了两组的血压水平，胰岛素敏感指数升高，抵抗指数降低。结论 罗格列酮治疗2型糖尿病伴有高血压的患者的时候，在降低血浆胰岛素水平、改善IR的同时，能够明显降低血压。     

控制血糖对老年原发性高血压合并2型糖尿病患者血压变异性的影响

目的探讨控制血糖对老年原发性高血压（EH）合并2型糖尿病（T2DM）患者血压变异性（BPV）的影响。方法临床确诊60例EH合并T2DM老年患者,糖化血红蛋白（HbA1c）含量检测均〉8.0 mmol/L,在给予原有抗高血压药物治疗同时,行控制血糖治疗3月后复查HbA1c,根据检测指标分为2组：A组为HbA1c达标组（HbA1c〈7.0 mmol/L）,B组为HbA1c未达标组（HbA1c〉7.0 mmol/L）。控制血糖治疗前后分别进行动态血压测定,比较患者BPV的变化。以各时间段血压的标准差（SD）作为血压变异的指标：24 h收缩压变异（24hSSD）和24 h舒张压变异（24hDSD）、白昼收缩压变异（dSSD）和舒张压变异（dDSD）、夜间收缩压变异（nSSD）和舒张压变异（nDSD）。结果 （1）EH合并T2DM患者,行控制血糖治疗HbA1c达标组治疗后与治疗前比较,24hDSD、dDSD、nDSD无显著差异（P〉0.05）,24hSSD、dSSD、nSSD有显著差异（P〈0.05）。（2）EH合并T2DM患者,行控制血糖治疗HbA1c未达标组治疗后与治疗前比较,患者的24hSSD、24hDSD、dSSD、dDSD、nDSD均无显著差异（P〉0.05）,nSSD有显著差异（P〈0.05）。（3）EH合并T2DM患者24hSSD、24hDSD变化与HbA1c含量呈正相关（r=0.531、0.667,P〈0.05）。结论在原有抗高血压药物治疗同时,控制血糖治疗可显著改善EH合并T2DM患者的BPV,改善其心血管系统血流动力学,从而减少心血管病并发症。     

Effects of reducing blood pressure on renal outcomes in patients with type 2 diabetes: Focus on SGLT2 inhibitors and EMPA-REG OUTCOME

Empagliflozin, a sodium–glucose cotransporter type 2 (SGLT2) inhibitor, has enabled remarkable reductions in cardiovascular and all-cause mortality as well as in renal outcomes in patients with type 2 diabetes (T2D) and a history of cardiovascular disease in the EMPA-REG OUTCOME. These results have been attributed to haemodynamic rather than metabolic effects, in part due to the osmotic/diuretic action of empagliflozin and the reduction in arterial blood pressure (BP). The present narrative review includes the results of meta-analyses of trials evaluating the effects on renal outcomes of lowering BP in patients with T2D, with a special focus on the influence of baseline and achieved systolic BP, and compares the renal outcome results of the EMPA-REG OUTCOME with those of other major trials with inhibitors of the renin–angiotensin system in patients with T2D and the preliminary findings with other SGLT2 inhibitors, and also evaluates post hoc analyses from the EMPA-REG OUTCOME of special interest as regards the BP-lowering hypothesis and renal function. While systemic BP reduction associated to empagliflozin therapy may have contributed to the renal benefits reported in EMPA-REG OUTCOME, other local mechanisms related to kidney homoeostasis most probably also played a role in the overall protection observed in the trial.     

Predictors of blood pressure control in patients with diabetes and hypertension seen in primary care clinics

BACKGROUND: Blood pressure (BP) is not well controlled in the majority of patients with both diabetes and hypertension. This study was designed to identify predictors of BP control in patients with both diabetes and hypertension who are seen in primary care clinics. METHODS: This retrospective study was conducted by identifying a cohort of patients diagnosed with diabetes before January 1, 2000 (inception) who met predefined criteria for hypertension at inception and who received primary care in the ensuing 3-year study period (January 1, 2000, to February 31, 2002). Using the mean of all BP values between January 1, 2002, and December 31, 2002, subjects were divided into two groups: those with controlled BP and those with uncontrolled BP. The distribution of clinical predictors was compared between the two groups. Independent predictors were identified using multivariate logistic regression. RESULTS: Predictors of poor BP control were as follows: 1) isolated systolic hypertension at inception (OR= 0.62, CI = 0.47 to 0.82); 2) uncontrolled BP at inception (OR = 0.71, CI = 0.55 to 0.93); 3) use of oral hypoglycemic drugs versus diet and exercise alone or insulin use (OR = 0.73, CI = 0.56 to 0.95); 4) use of three or more antihypertensive drugs (OR = 0.74, CI = 0.56 to 0.97); and 5) older age (OR = 0.98, CI = 0.97 to 0.99). Predictors of better control were 1) use of nitrates (OR = 1.82, CI = 1.26 to 2.64); 2) history of coronary heart disease (OR = 1.47, CI = 1.08 to 2.00); and 3) at least one annual visit to subspecialist physician (OR = 1.43, CI = 1.09 to 1.88). CONCLUSIONS: Patients with both diabetes and hypertension who are older, have isolated systolic hypertension, use oral hypoglycemic drugs, or use three or more antihypertensive drugs should be targeted for better BP control. The roles of nitrate medication and subspecialist physicians in achieving better BP control needs further study.     

罗格列酮对2型糖尿病合并高血压患者血压的作用

目的：运用胰岛素增敏剂罗格列酮治疗2型糖尿病伴高血压患者，研究其降压作用及降压机理。方法：38例2型糖尿病伴高血压患者，口服罗格列酮（文迪雅）4～8mg／d，共12周，观察治疗前后的血压、瘦素、血糖和胰岛素水平，计算胰岛素敏感指数和胰岛素抵抗指数，并进行分析比较。结果：罗格列酮治疗后收缩压和舒张压明显下降（P〈0．05）；甘油三酯（TG）、空腹血糖（FBG）、餐后血糖（PBG）、空腹胰岛素（FINS）和餐后胰岛素（PINS）均明显降低（P均〈0．05）；瘦素水平明显升高（P〈0．01）；胰岛素敏感性指数（ISI）显著升高（P〈0．05），胰岛素抵抗指数（IR）显著下降（P〈0．05）。结论：罗格列酮在降低血糖、改善胰岛索抵抗、提高胰岛素敏感指数的同时，具有升高瘦素水平和降低血压的作用。